Patient Pre-Registration

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Demographics

***Please ensure that the patient name and date of birth are identical to the information appearing on the patient's government issued ID***

Patient Last Name *

Patient First Name *

Middle Initial

Patient Date of Birth *

Patient Street Address *

Patient Address Line 2

Patient City *

Patient State / Province *

Patient Zip Code *

Patient Email Address *

Patient Mobile Number *

Sex *

Race *

Ethnicity *

Please enter your driver's license information OR your primary insurance number for identification purposes.

Please upload an image of your id and enter your drivers license number [If appropriate input is provided].

ID Card (Parent/Guardian ID for patients under 18) Please take a photo of your id card and upload.

Drivers license number

ORANGE COUNTY EDUCATIONAL ARTS ACADEMY INFORMED CONSENT/AUTHORIZATION FOR COVID-19 TESTING Please carefully read the following informed consent: 1. I am an Orange County Educational Arts Academy (“OCEAA”) student, parent of an OCEAA student, faculty, staff member of OCEAA, OCEAA authorized/approved volunteer, or OCEAA authorized/approved contractor providing services for OCEAA students (hereinafter “student or staff member”), and I authorize Orange County Educational Arts Academy and/or an independent laboratory acting on OCEAA’s behalf to conduct collection and testing for exposure to the Novel Coronavirus (COVID-19) through a mouth swab, saliva sample, or other minimally or non-invasive sample collection method as ordered by an authorized medical provider. 2. I understand that a minimally invasive sample collection method will be used to conduct the testing through the mouth/oral swab causing minimum discomfort. 3. I understand that OCEAA’s independent laboratory partners are operating, as permitted under applicable laws and regulations, at various stages of the U.S. Food and Drug Administration’s Emergency Use Authorization submission, acknowledgment, and approval process. 4. I understand that, if the student, faculty, or staff member receives a positive test result, I must ensure that the student, staff or faculty abides by all applicable federal, state and/or local requirements with respect to isolation and quarantine to avoid infecting others. 5. I understand that, in the event of a positive test, OCEAA and/or individuals or contractors acting on its behalf, may contact me and those who may have been exposed to the student, faculty, or staff member and the student, faculty, or staff member’s identity may be disclosed to certain individuals to the extent necessary to protect the health and safety of those exposed. 6. I understand that by signing this document I accept and agree that the student, faculty, or staff member shall undergo COVID19 testing, that I am not creating a patient relationship with OCEAA. I understand that OCEAA is not acting as a medical provider for the student, faculty, or staff member. Testing does not replace treatment by a medical provider. I understand that the OCEAA testing program is only intended to determine the existence of COVID-19 for the purpose of coming onto a school campus and I am not relying on this program for personal reliance. I agree that it is my responsibility to take appropriate action with regards to the test results for the student, faculty, or staff member. I agree it is my responsibility to seek medical advice, care and treatment from a medical provider for the student, faculty, or staff member to the extent such medical advice, care and treatment becomes necessary. I further agree not to hold OCEAA or its agents and contract partners liable for the acts and health care made available or introduced as part of this testing program. 7. I understand that, as with any medical test, there is the potential for false positive or false negative test results to occur. 8. I understand that OCEAA has engaged certain third-party contractors and consultants to assist it in administering its COVID19 testing program. I further understand that in order for the COVID-19 testing program to be successfully administered, certain personal information regarding the student, faculty, or staff member will need to be communicated to such contractors and consultants for purposes of administering the program, and only to the extent necessary to the administration of the COVID19 testing program. This includes certain information contained within OCEAA’s Powerschool Student Information System, and may include personally identifiable information protected under the Family Educational Rights and Privacy Act, including student name, school, grade level, and cohort. I hereby expressly authorize such information regarding the student, faculty, or staff member to be disclosed as described herein to the extent necessary to the administration of the COVID-19 testing program. 9. I understand that neither my family nor I will be charged directly for services. Third-party payment sources may be billed. 10. By signing this form, I acknowledge that this consent & authorization is for COVID-19 testing during the 2022-2023 school year, starting August 3, 2022 and continuing through May 31, 2023. This testing will occur weekly but may also be modified to occur twice in a ten-day period, in accordance with the guidelines from the United States Centers for Disease Control and Prevention, California Department of Public Health, and OCEAA. 11. By signing this form, I acknowledge that I have received a copy of OCEAA’s Notice of Privacy Practices. 12. While I understand that medical records will be kept in a confidential manner, I acknowledge and allow the release of information regarding treatment to third party payors such as Medi-Cal or insurance companies for the purpose of billing. I also acknowledge and agree to allow information such as immunization history and/or communicable disease may be shared with OCEAA to protect the health of other students, faculty, or staff members. I acknowledge and agree that information may also be disclosed to certified third parties to facilitate the transmission of electronic health records. ACCEPTANCE: I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, I have been given the opportunity to ask questions before I consent, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19. OFFICE USE ONLY Signature Verified by:____________________________________________________________________ Date:__________________ ORANGE COUNTY EDUCATIONAL ARTS ACADEMY STUDENT HEALTH AND HUMAN SERVICES NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you or your child may be used and released and how you can get access to this information. Please review this document carefully. Orange County Educational Arts Academy (OCEAA) and its contract agents/schools are required by federal law, the Health Insurance Portability and Accountability Act (HIPAA), to make sure that your Protected Health Information (PHI) is kept private. PHI includes information that we have created or received about you or your child’s past, present, or future health/medical conditions that could be used to identify you or your child. Unless you give us written authorization, we will only release your health/medical information for treatment, payment, or health care operations or when we are otherwise required or permitted by law to do so. Not every use is listed, but the ways we can use, and release information fall within one of the descriptions below. 1. Appointment reminders and health-related benefits or services: We may use PHI to send you appointment reminders. We may also use PHI to give you information about other health care related treatment and services. 2. Treatment: We may use and release your PHI to those who provide you with health care services or who are involved with you or your child’s care such as doctors, nurses and other health care professionals. PHI may also be used for referrals to hospitals, specialists, or for other treatment alternatives. For example, we may share the PHI with relevant school staff for Individualized Educational Program (IEP) purposes to recommend appropriate Special Education related services to address your child’s health needs while at school. 3. To receive payment for the treatment that was provided to you or your child: We may use and release your PHI in order to bill and receive payment for treatment and services you or your child received in the school or community setting. For example, OCEAA’s contract providers will bill governmental agencies or insurance companies testing and medical services. 4. Health Care Operations: We may use and release your PHI in order to administer our school-based health centers. For example, members of our quality improvement team may use information in you or your child’s health record to review the care and outcomes for quality improvement purposes. 5. To meet legal requirements: We may use and release PHI to government officials or law enforcement agencies when federal, state, or local laws require us to do so. We also share PHI when we are required to do so in a court or other legal proceedings. For example, if a law says we must report private information about students, who have been abused, we will provide such information. 6. To report Public Health activities: We may use and release PHI to government officials in charge of collecting certain public health information. For example, we share general information about immunizations, deaths, and some statistical information about diseases such as pertussis or chickenpox. 7. For Research purposes: We do not release PHI for purposes of medical research. We do, however, use PHI to create a collection of information that cannot be traced back to you or your child. 8. To avoid harm: In order to avoid a serious threat to the health and safety of a person or the public, we may provide PHI to law enforcement, emergency personnel, or others who may be able to stop or lessen the harm. 9. Funding: We may use and release the PHI toward applying for grants and/or government funding agencies to obtain funds for the enhancement and expansion of our services. (Although allowable by law, it is not OCEAA’s practice to use or release your PHI in a manner that can be traced back to you or your child.) Your Rights ● To see or obtain a copy of information that we have about you or your child or correct you or your child’s personal information that you believe is missing or incorrect. If someone else (such as your doctor) gave us the information, we will tell you who, so that you can ask them to correct it. ● To ask us not to use your health information for payment or health care operations activities. (We are not required to agree to these requests.) ● To ask us to communicate with you about health matters using reasonable alternative means or at a different address, if communications to your home address could endanger you. ● You have a right to withdraw or revoke your consent in writing at any time. However, we may refuse to continue to treat a child if the parent revokes his or her consent. ● Receive a list of disclosures of your health information that we make, except when: o You have authorized the disclosure; o The disclosure is made for treatment, payment or health care operations; or o The law otherwise restricts the accounting. If you have any questions, please call Orange County Educational Arts Academy at (714) 558-2787. Complaint Process: If you believe that we may have violated your Privacy Rights, you may send your written complaint to: Orange County Educational Arts Academy 825 North Broadway, Santa Ana, CA 92701

* Parent/Guardian Minor Consent

Parent/Guardian Name *

Relationship To Patient *

Primary Insurance

Insurance Provider

Member ID

Group Number (Optional)

Medical Insurance Card - FRONT

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK

Please take a photo of the back of your insurance card and upload.

Secondary Insurance

Insurance Provider

Member ID

Group Number (Optional)

Medical Insurance Card - FRONT

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK

Please take a photo of the back of your insurance card and upload.

Tertiary Insurance

Insurance Provider

Member ID

Group Number (Optional)

Medical Insurance Card - FRONT

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK

Please take a photo of the back of your insurance card and upload.

*By clicking submit the patient gives authorization for test results and associated protected health information (PHI) to be sent via digital delivery methods including SMS text and email.
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